SummaryThe Alaska Dental Health Aide Program increases access to oral health care by training new types of dental providers to provide culturally appropriate education and routine dental services under the supervision of a dentist to high-risk residents (e.g., children, pregnant women, and other high-risk groups) of rural villages. Since 2004, 20 dental therapists have completed a 2-year training program and are providing dedicated access to care for more than 35,000 of Alaska's rural residents. These communities typically had no dedicated oral health care provider or programs to encourage engagement in oral health care, prevention, and literacy.Suggestive: The evidence consists of post-implementation data on services provided along with two independent evaluations and an implementation evaluation that evaluated the effectiveness and quality of services provided.
Developing OrganizationsAlaska Native Tribal Health Consortium (ANTHC)
Date First Implemented2003
February 2003 (The first six students went to New Zealand for training at this time.)
Race and Ethnicity > American Indian or Alaska native; Vulnerable Populations > Children; Impoverished; Racial minorities; Rural populations
Problem AddressedOral diseases disproportionately affect American Indian and Alaska Native people (compared with the general U.S. population).1 Lack of access to professional care contributes significantly to these disparities.
- High prevalence of oral diseases: Alaska Native children face a 2.5-times higher risk of dental caries (decay) than the average American.2 American Indian and Alaska Native children between the ages of 2 and 4 have the highest rate of decay in the United States—five times the national average.1 Alaska Native adults also suffer disproportionately high rates of oral disease.
- Significant impact: One-third of school-age children in rural Alaska miss school because of dental pain,2 and one-fourth report avoiding laughing or smiling because of the appearance of their teeth.1 By the time they reach adulthood, many have already experienced devastating consequences due to lack of dental care.2
- Lack of access to professional care: Approximately 85,000 Alaska Native people live in small villages of 300 to 400 people, accessible only by air or water; villagers often have to travel hundreds of miles to obtain dental care. There is one dentist for every 2,800 individuals in the Indian Health Services and tribal health clinics, compared with one dentist for every 1,500 individuals in the general U.S. population.1 A scarcity of dentists of American Indian or Alaska Native ethnicity further contributes to the access problem, making it especially difficult for Alaska Native people to get culturally competent care.1,2
Description of the Innovative ActivityThe Alaska Dental Health Aide program enhances access to dental care by training new types of providers, including dental health aide therapists, to provide culturally appropriate education and routine dental services to high-risk residents of rural Alaska villages under the supervision of a dentist. Alaska dental therapists are committed to the regions where they live and serve, often possessing language skills and cultural fluency to be effective advocates of oral care in their home region, and offer oral health services never before available in rural Alaska. Key program elements are described below:
- Recruitment: Regional Alaska Native health organizations recruit dental health aide candidates with strong community ties to work in their regions. Candidates for the program include primary dental health aides, expanded function dental health aides, dental health aide hygienists, and dental health aide therapists (who apply to the University of Washington DENTEX program).
- Training, mentoring, and certification: Dental health aides have different levels of on-the-job training and certification, certified according to federal Community Health Aide standards. Dental health aide therapists receive the highest level of training and go through an extensive education and certification process, as outlined below:
- Training: The first Alaska dental therapists were trained at the University of Otago in New Zealand. The curriculum for a Diploma in Dental Therapy includes courses in general health science, oral health science, society and health, clinical dentistry, and dental therapy practice. Accepted applicants complete a 2-year training program that includes 2,400 hours of classroom training and clinical experience. They spend approximately 760 hours treating children in local clinics, along with 4 weeks in the field learning the responsibilities of a dental therapist. In 2007, the Alaska Native Tribal Health Consortium began its own training program in collaboration with the University of Washington School of Medicine Physician Assistant training program, MEDEX Northwest. Based on the New Zealand model, the curriculum has been tailored to rural Alaska's oral health care needs. Students spend the first year training in Anchorage and the second year in Bethel, where clinical training includes 3 weeks of village travel.
- Protracted preceptorship: After training, dental therapists return to their sponsoring communities to complete a 400-hour preceptorship (practical experience and training) under the supervision of a dentist employed by the sponsoring tribal health organization and located in a hospital that serves the village. The dentist writes standing orders, serves as the point of contact for the dental therapist, and evaluates the dental therapist's skills through direct observation.
- Certification: The Community Health Aide Certification Board (a 12-member board of experienced Federal, State, and tribal health professionals appointed by Indian Health Services) administers a certification program. Dental therapists must meet the qualifications outlined in the Federal Community Health Aide Program Standards and Procedures. The Board can revoke or suspend the certificates of dental therapists who do not meet competency standards. Recertification occurs biennially and requires reevaluation by the supervising dentist.
- Oral health services: Dental therapists provide a variety of oral health services, including education, preventive services, and basic treatment, as outlined below:
- Education and prevention: Dental therapists provide oral health education at schools and develop community prevention strategies for their villages. For example, one of the dental therapists living in a Kotzebue village visits the local school each day to provide preventive services such as setting up tooth brushing and fluoride supplement programs and educating the children about the importance of oral health. Dental therapists sometimes supervise primary dental health aides, whose scope of practice includes oral health education and topical fluoride application.
- Dental services: Dental therapists provide year-round services in regional hub clinics and remote village clinics. Although the program increases access to dental services for all Alaska Native people living in rural areas, it focuses on reaching children, pregnant women, and other high-risk residents. Dental therapists treat dental caries, primarily in children, and provide preventive services, such as fluorides, sealants, cleanings, pulpotomies, and uncomplicated tooth extractions to preserve function and address pain or infection.
- Consultation through telehealth network: As necessary, supervising dentists (who work out of the hub hospital that serves the respective village) can connect to the dental therapist via a telehealth network that allows the transfer of real-time digital images from remote locations, enabling the dentist to view the teeth and x-rays along with the therapist. Patients whose needs go beyond the scope of a dental therapist, as well as patients with any significant health history or special needs, typically require a consultation with the dentist.
- Reimbursement: Under a Federal agreement, dental therapists bill the Medicaid program directly for the services they provide to receive reimbursement.
References/Related ArticlesAlaska Native Tribal Health Consortium. Alaska Dental Health Aide Therapist Initiative [Web site]. Available at: http://www.anthc.org/chs/chap/dhs/index.cfm
Bolin KA. Assessment of treatment provided by dental health aide therapists in Alaska - a pilot study. J Am Dent Assoc. 2008;139(11):1530-35. [PubMed]
Nash DA, Nagel RJ. A brief history and current status of a dental therapy initiative in the United States. J Dent Educ. 2005;69(8):857-9. [PubMed]
Contact the InnovatorMary Williard, DDS, LCDR USPHS, IHS
Alaska Area Dental Officer
Dental Health Aide Therapist Ed. Program Director
Alaska Native Tribal Health Consortium
4200 Lake Otis Parkway, Suite 204
Anchorage, AK 99508
Phone: (907) 729-5602
Fax: (907) 729-5610
Innovator DisclosuresDr. Williard has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
ResultsPost-implementation usage data suggests that the program has enhanced access to quality oral health services for individuals living in rural Alaska villages who previously had limited or no access to such services. Two independent evaluations found the program to be effective, while an implementation evaluation suggests high levels of patient satisfaction and quality of care.
Suggestive: The evidence consists of post-implementation data on services provided along with two independent evaluations and an implementation evaluation that evaluated the effectiveness and quality of services provided.
- Enhanced access: As of 2011, 20 dental therapists served 42 villages in Alaska (up from 20 villages in 2007), providing year-round services to more than 35,000 rural Alaskans who previously had access to services only a few weeks a year. For example, the first class of dental therapists has brought dental care to hundreds of patients in two remote Alaska villages (Bethel and Kotzebue) that previously had limited or no access to such services:
- Bethel: Between February 1, 2005, and August 31, 2005, the two dental therapists completed 375 examinations, 519 preventive services, 242 restorations, 13 stainless steel crowns, 16 pulpotomies, and 171 extractions.
- Kotzebue: In this same period, the two dental therapists in Kotzebue saw 857 patients and completed 390 examinations, 745 preventive services, 576 restorations, and 89 extractions.
- High-quality, effective care: Two independent evaluators plus results from an implementation evaluation found the Alaska program to be of very high quality.
- First evaluation: A professor of dentistry from the University of Washington found that the first four dental therapists employed in Alaska met evaluators' standards for record review, cavity preparation and restoration, patient management, and patient safety. He recommended that the program not only continue, but be expanded.3
- Second evaluation: A professor of dentistry from Texas A&M University concluded that the dental treatment performed by dental therapists was within their scope of training, delivered in a safe manner, and met the standard of care of the dental profession. He also found no statistically significant difference in the rate of complications resulting from treatment delivered by dental therapists and dentists.4
- Implementation evaluation: A study published in October 2010 evaluated the implementation of the dental health aide therapist program in five Alaskan villages. Surveys, interviews, technical performance measurements (through examination of patients with previous dental restorations), chart audits, and facility evaluations indicate high levels of patient satisfaction and demonstrate that the therapists provide safe, competent, appropriate care.5
Context of the InnovationThe Alaska Native Tribal Health Consortium is a nonprofit health organization owned and managed by local Alaska Native tribal governments and their regional health organizations. The genesis for the dental therapist program came from discussions that Alaska Native Tribal Health Consortium leaders had with oral health experts. The consortium first learned about the program at an Oral Health America conference held in 2000, at which attendees discussed the potential of a New Zealand–style dental therapist to reduce oral health disparities. In February 2001, a larger group of interested parties met at the Forsyth Institute in Boston to examine the possible role of the dental therapist and to consider how to seek funding for a training program and trial initiative. After this meeting, the parties decided to target American Indian and Alaska Native people, who experience inordinate disparities in oral health and access to dental care. The parties also believed that oral health therapists could be relatively easily deployed in these communities, because tribes are sovereign entities.
Planning and Development ProcessKey steps included the following:
- Conceptualizing the model: Concurrent with the discussions described in the previous section, the Alaska Native Tribal Health Consortium and its component tribes began the development of the program under the provisions of the Community Health Aide program. Project leaders conceptualized three levels of dental health aides, including the primary dental health aide, the expanded function dental health aide, and the dental therapist. Both the primary and extended function dental health aides would work under the direct supervision of a dentist, while the dental therapist would be trained to work in consultation with a dentist.
- Training agreement and initial funding: In 2003, the School of Dentistry at the University of Otago in New Zealand agreed to accept six Alaska Native students per year into its dental therapy training program. Project leaders chose this school because of its international reputation and its more than 85 years of experience with the dental therapist practice model. At the time, no such program existed in the United States. The Rasmuson Foundation provided initial funding to support for the training and travel.
- Initial class: The first six students entered training in February 2003, with four of the six completing training in December 2004 and starting their preceptorships in January 2005 in the villages of Bethel and Kotzebue. One more student completed the curriculum and started the preceptorship in Kotzebue in August 2005.
Resources Used and Skills Needed
- Staffing: The Alaska Native Tribal Health Consortium provides administrative oversight. A clinical program director (a dentist) oversees training of dental therapy students. Visiting faculty give lectures to dental therapists at clinics as part of their training. Dentists and hygienists, who may already be employed in regional or village clinics, also constitute members of the dental team.
- Costs: Information provided in December 2011 indicates that the total cost of training an Alaska Native student in Alaska (including travel, books, and tuition) runs approximately $75,000. Operating costs include both infrastructure costs (e.g., staff salaries and benefits), equipment costs, facility rental costs, travel, and contracting of professional services for delivery of the curriculum.
Funding SourcesHealth Resources and Services Administration; Robert Wood Johnson Foundation; Rasmuson Foundation; Paul G. Allen Charitable Trust; Ford Foundation; Alaska Mental Health Trust; Denali Commission; Natural Rural Funders; Indian Health Service (IHS); W.K. Kellogg Foundation; Healthy Alaska Natives Foundation; Murdock Charitable Trust
The Rasmuson Foundation provided initial funding to support the training, including travel to the school in New Zealand.
Getting Started with This Innovation
- Get commitment from the community: The need for such a program must be locally driven, with the people who want services asking the health care community to make it happen. In this case, local interest existed; the program was perceived as a good nonseasonal job opportunity for residents (allowing individuals to learn clinical skills, develop relationships with patients, and gain standing in the community) and an effective way to improve the oral health of residents.
- Work closely with dental community to get buy-in: "Sell" the program to dentists by convincing them to think of themselves as leaders of an expanded dental team, rather than as sole providers. In addition, emphasize the ability of the dental therapist model to expand services to individuals who previously had little or no access to any dental services.
- Ensure that solid legal framework exists: State and Federal policies provide the legal basis for this program. Tribal management of Indian Health Services programs is authorized by the Indian Self-Determination and Education Assistance Act. Dental therapists receive certification and operate under the auspices of Alaska's Community Health Aide program, authorized by Section 121 of the Indian Health Care Improvement Act6 (not the Alaska State Medical Act or Dental Practice Act). Consequently, the program can use its own certification process. Programs in other geographic areas or settings, however, may not be legally able to do the same without a policy change or waiver.
Sustaining This Innovation
- Develop viable economic model: The ongoing operations of this program depend on reimbursement for services provided by dental therapists (e.g., through Medicaid). This program makes the provision of oral health services under the Medicaid program economically viable, something that many other dentist-based programs have failed to do.
Use By Other Organizations
- According to the World Health Organization, 42 countries employ some variant of the dental health aide model.1 As noted, the model originated in New Zealand, where it has led to measurable improvements in the oral health status of residents. Canada has also had a great deal of success in implementing a similar program for its tribal population.
Nash DA, Nagel RJ. Confronting oral health disparities among American Indian/Alaska Native children: the pediatric oral health therapist. Am J Public Health. 2005;95(8):1325-9. [PubMed]
4 Bolin KA. Quality assessment of dental treatment provided by dental health aide therapists in Alaska. Paper presented at the National Oral Health Conference; May 1, 2007.
6 Alaska Dental Health Aide Program Brief. Alaska Native Tribal Health Consortium.
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Service Delivery Innovation Profile
Original publication: November 11, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: May 16, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: December 05, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.